目的 观察银杏二萜内酯葡胺注射液(DGMI)对急性缺血性脑卒中(AIS)再通成功患者预后的影响.方法 回顾性选取南京大学医学院附属鼓楼医院和南京医科大学第一附属医院2016年6月-2021年12月收治的AIS再通治疗患者为研究对象,共纳入颈内动脉或大脑中动脉闭塞者206例.根据再通治疗后3d头颅磁共振血管造影(MRA)检查结果,将206例患者分为开通成功患者(n=157,其中61例接受DGMI治疗)和开通失败患者(n=49,其中21接例受DGMI治疗);以患者是否接受过DGMI治疗为依据,将接受DGMI治疗≥7 d的患者设为试验组(n=82),未接受DGMI治疗的为对照组(n=124).收集的临床资料包括年龄、性别、发病至干预时间、干预方式、不良事件(症状性脑出血、死亡)、发病时和90 d的美国国立卫生研究院卒中量表(NIHSS)评分和改良Rankin评分量表(mRS)评分.分别比较开通成功患者和开通失败患者中对照组和试验组间不良事件发生率和预后的差异,包括症状性脑出血率、死亡率,以及90d后的NIHSS改善率和mRS评分.结果 开通成功患者中,试验组90dNIHSS改善率和mRS评分均明显优于对照组(P＜0.05);而在开通失败患者中两组间90dNIHSS改善率和mRS评分比较,差异无统计学意义(P＞0.05);对照组和试验组的症状性脑出血率和死亡率在两亚组中均无明显差异(P＞0.05).结论 对于接受再通治疗的AIS患者,DGMI有利于再通成功患者的神经功能改善,且不增加不良事件发生风险.

心脏骤停（cardiac arrest, CA）是世界范围内严重的公众健康问题，也是成人死亡和神经功能损伤的主要原因之一 [1]。随着心肺复苏（cardiopulmonary resuscitation, CPR）技术和体外生命支持理念的不断进步，越来越多的CA患者能够实现自主循环恢复（return of spontaneous circulation, ROSC）。然而，CA后缺血缺氧性脑损伤是影响患者病死率和致残率的重要因素 [2]。据统计，美国成人院外CA（out-of-hospital CA, OHCA）年发患者数超过356 000例，出院成活率为10.4%，神经功能预后良好患者占8.2%。院内CA（in-hospital CA, IHCA）发病率平均为10.16/1000住院患者，出院存活率为25.8%，预后良好患者占82% [3]。我国北京地区CA患者预后评价研究表明，OHCA及IHCA患者出院成活率分别为1.3%和9.1%，神经功能预后良好患者仅占1%和6.4% [4,5]。

目的 总结体外膜肺氧合辅助心肺复苏治疗(ECPR)的心源性心脏骤停(CA)患者的胸部影像学特点.方法 回顾性分析2015年5月至2021年3月所有ECPR患者的胸部影像学特点.纳入肺部病变符合重力依赖性分布的患者,分别依据胸部正位X线片和胸部CT平扫计算RALE评分和CT评分.Bland-Altman分析法分析两名影像科医师评分的一致率.结果 最终纳30例患者,其中男26例,女4例,平均年龄(46±18)岁,常规心肺复苏时间(CCPR)(38±14)min、ECMO 穿刺至转机时间(15±2)min、CA 发生至 CT 检查时间 92 min(29 min,79 min).30例患者中,磨玻璃病变及斑片状实变发生率最高,为90％(27/30),小叶间隔增厚及支气管血管束征分别为86.7％(26/30)、73.3％(22/30),支气管充气征 56.7％(17/30),心包积液的发生率最低,为 20％(6/30).Bland-Alt-man 分析法评价影像科医师之间评分的一致率为96.7％[RALE评分95％CI(-5.475,5.609);CT评分95％CI(-6.969,4.103)].双肺 RALE 评分 37.4±11.1,左、右肺 RALE 评分无统计学差异(20.3±6.8 vs.17.8±7.1)(P=0.091).肺上区CT积分(4.1±2.3)显著低于肺中区(9.7±3.4)及肺下区(15.1±3.6)(P＜0.01),肺中区和肺下区之间CT评分也有统计学差异(P＜0.01).肺前区CT评分显著低于肺后区(16.4±2.9 vs.21.3±4.5)(P＜0.01).肺水肿占比34.5±13.5(％).结论 心源性CA患者的胸部CT可表现为重力依赖性分布的特点,这一特征性影像的临床意义尚不清楚,需要进一步的研究.

近年来体外膜氧合(extracporeal membrane oxygenation,ECMO)技术在危重症患者抢救中的应用越来越广泛[1-3],尤其新冠肺炎在世界范围内的流行进一步增加了人们对此项技术的认识,刺激了更多的医院开展体外膜氧合技术,俯卧位通气作为急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)治疗的一项重要手段在配合静脉静脉体外膜氧合(VV-ECMO)技术的使用中快速增长[4].

农药中毒是我国中毒和意外死亡的主要病因，随着百草枯的禁止销售和使用，敌草快（diquat, DQ）成为首选的联吡啶类除草剂。近年来DQ中毒病例持续增多，是目前中毒研究的热点 [1]。DQ中毒主要通过脂质过氧化反应产生氧自由基损伤细胞膜，导致细胞死亡，预后与摄入量存在明确相关性，对人的致死量为6~12 g（即浓度为20%的DQ溶液56.10~112.20 mL），尚无特效解毒剂 [2]。值得注意的是，肾脏既是DQ吸收后的主要排泄器官，也是DQ毒性损伤的主要靶器官 [2,3]。无论是多见的经消化道途径，还是本团队报道的经肌肉注射途径中毒病例 [4]，DQ中毒患者均易发生急性肾损伤。为了更好地了解DQ中毒致肾脏损伤的病理特点，既往研究仅有尸检病理报道 [5]，南京医科大学中毒研究所首次取得2例DQ中毒患者的肾活检病理（南京医科大学第一附属医院伦审号：2020-SR-099），总结相关临床资料和病理结果报道如下。

目的 探究血清同型半胱氨酸(Hcy)、总胆红素(TBIL)、胱抑素C(Cys C)3种血清标志物与老年扩张型心肌病(DCM)患者心脏功能的相关性及对预后的预测价值.方法 以2017年1月～2019年12月在南京医科大学第四附属医院就诊的200例DCM患者为研究对象,根据心功能分级(NYHA)标准分为心功能Ⅱ级组(66例)、心功能Ⅲ级组(80例)、心功能Ⅳ级组(54例).收集一般资料,对所有患者进行超声心动图检测,测量并计算左心房内径(LAD)、左心室舒张末期内径(LVEDD)、左心室舒张末期容积(LVEDV)、LVEF,检测血清Hcy、Cys C、TBIL,采用Pearson或Spearman进行相关性分析.进行2年随访,采用单因素和多因素logistic回归分析确定预后的独立风险因素,采用ROC曲线图判断独立危险因素的预测价值.结果 3组的LAD、LVEDD、LVEDV、LVEF、Hcy、TBIL、Cys C比较差异有统计学意义(P<0.05),随着心功能分级升高,LAD、LVEDD、LVEDV、Hcy、TBIL、Cys C显著升高,LVEF显著下降,差异有统计学意义(P<0.05).血清Hcy、TBIL、Cys C与LAD、LVEDD、LVEDV、心功能分级呈正相关(P<0.01),与LVEF呈负相关(P<0.05,P<0.01).多因素logistic回归分析表明,LVEDD、Hcy、TBIL、Cys C是DCM患者死亡的独立风险因素(P<0.05);Hcy、TBIL、Cys C、LVEDD的ROC曲线下面积分别为0.724(95％CI:0.653～0.794)、0.754(95％CI:0.685～0.823)、0.824(95％CI:0.759～0.888)、0.678(95％CI:0.603～0.753).结论 血清Hcy、Cys C、TBIL与DCM患者心功能存在显著相关性,是不良预后的独立危险因素,对DCM患者的预后具有预测价值.

Objective:To investigate the implementation status of sepsis hour-1 bundle strategy for patients with septic shock in emergency department.Methods:A total of 116 septic shock patients admitted to the emergency department from January 2020 to December 2020 were included in this prospective study, and the implementation of sepsis bundles and the clinical outcomes of patients were recorded.Results:Among 116 patients, 20 cases (17.2%) had lactic acid monitored within 1 h, 20 cases (17.2%) had blood culture before antibiotics, 82 cases (70.1%) received broad-spectrum antibiotics, 16 cases (13.8%) received fluid resuscitation ≥30 ml/kg, and 57 cases (49.1%) received vasoactive drugs during resuscitation. Finally, the sepsis hour-1 bundle strategy was fully implemented only in 13 cases (11.2%). Compared with the group with incomplete implementation of sepsis hour-1 bundle strategy, the volume of fluid recovery in the group with full implementation was significantly increased [33.7 (30.0,37.5) vs. 8.9(7.3,10.8) ml/kg, Z=-4.78, P<0.001], mean artery blood pressure significantly increased [70.0 (70.0,76.7) vs. 67.7 (61.7,76.7)mmHg(1 mmHg=0.133 kPa) , Z=-2.00, P<0.001], and lactic acid significantly decreased [3.0 (2.0,3.2) vs. 4.4 (3.7,7.2) mmol/L, Z=-2.76, P=0.006]. However, there were no significant differences in ICU mortality, in-hospital mortality and 28-day mortality between the two groups ( P>0.05). Conclusions:Septic shock patients in emergency department have poor compliance with the implementation of sepsis hour-1 bundle strategy, and relevant management training should be strengthened.

目的 探讨在体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)上机初期,红细胞分布宽度(red blood cell volume distribution width,RDW)和血小板分布宽度(platelet distribution width,PDW)对急性心肌梗死患者预后的判断价值.方法 回顾性分析2017年4月至2021年7月期间接受静脉-动脉体外膜肺氧合(veno-arterial extracorporeal membrane oxygenation,VA-ECMO)治疗的急性心肌梗死患者.比较不同预后患者一般情况、ECMO上机前APACHEⅡ评分、治疗期间最高的氨基末端脑钠尿肽前体(N-terminal fragment of the brain natriuretic peptide precursor,NT-proBNP)和肌钙蛋白T数值.ECMO运行后即刻监测的血红蛋白、RDW、血小板计数、PDW和平均血小板体积.并记录同时期采血检测的活化部分凝血酶原时间.比较不同预后组上述指标的差异,并采用Logistic回归分析与预后的相关性.结果 入选55例,存活18例(32.8％),平均年龄(54.7±11.2)岁,其中男性48例(87.3％).存活组上机前前APACHEⅡ评分低于死亡组(分:26.00±6.54 vs.30.54±4.35,P<0.05).存活组RDW低于死亡组(％:12.57±0.60 vs.128.59±0.80);PDW在两组间差异无统计学意义(P>0.05).Logistic回归分析显示,上机前APACHEⅡ评分与患者预后相关,而RDW与患者预后不相关.结论 VA-ECMO支持的急性心肌梗死患者上机前APACHEⅡ评分可以预测患者预后,而RDW和PDW不适合作为患者预后判断指标.

体外膜肺氧合(ECMO)是一种短期辅助和生命支持系统 [1],作为现阶段应用广泛的抢救技术,其本质为使重症患者的心肺得以调整,并由患者机体对受损的心肺功能予以自我修复,其辅助治疗效果显著 [2].同时,ECMO治疗也有多重并发症,有研究 [3]认为,在接受ECMO治疗的患者中,出血与血栓是最常见的并发症之一.连续肾脏替代治疗(CRRT)则能够对患者的肾脏进行最大限度的模拟,以此对水及溶质予以持续、大量且缓慢地清除,由此稳定患者的机体内环境,并缓解其肺水肿症状 [4].CRRT通过对流模式溶解杂质及水分,清除体内代谢废物 [5].有研究 [6]认为,连续肾脏替代有利于调节机体免疫紊乱状态.

Objective:To evaluate the outcome of the patients receiving dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) delivered by first-responders who witnessed the out-of-hospital cardiac arrest (OHCA) before the Emergency Medical Service (EMS) arrived.Methods:We performed a search of the relevant literature exploring major scientific databases. We assessed the quality of the included cohort study according to the Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. Meta-analysis was performed on three outcome indicators (recovery of spontaneous circulation survival to hospital discharge and survival with favourable neurologic outcome) using the Revman5.3 software.Results:A total of 21 studies with 349 822 patients were selected for the meta-analysis, including 182 125 patients in the DA-CPR group and 167 697 in the CPR-only group. The meta-analysis showed no significant difference between the DA-CPR and CPR-only groups in ROSC [ RR=1.10, 95% confidence interval ( CI): 0.94-1.29, P=0.24], survival to hospital discharge ( RR=1.10, 95% CI: 0.90-1.34, P=0.34) and survival with favourable neurologic outcome ( RR=1.01, 95% CI: 0.79-1.28, P=0.97) of the patients in America, Japan and Korea. However, there was a significant difference between the DA-CPR and the CPR-only groups in ROSC ( RR=2.61, 95% CI:1.53-4.46, P=0.0005), survival to hospital discharge( RR=6.08, 95% CI: 1.84-20.04, P=0.003), and survival with favourable neurologic outcome( RR=9.76, 95% CI: 1.87-51.02, P=0.007) of the patients in China. Conclusions:The overall effect of DA-CPR is significantly different for each country. In detail, DA-CPR offers a survival advantage (Return of spontaneous circulation, survival to hospital discharge and survival with favourable neurologic outcome) over CPR alone in China but no advantage in developed countries.

目的 系统评价基于随机对照研究下植骨与非植骨2种方式对上颌窦侧壁窦底抬高术后即刻种植的疗效差异.方法 计算机不受限制地检索PubMed、Web of Science、Embase、Cochrane library、中国知网、万方数据库、维普等数据库对比植骨与非植骨对上颌窦侧壁窦底抬高术后即刻种植疗效的临床试验,检索时间为建库至2020年8月,文章采用Cochrane偏倚风险评估工具进行偏倚风险评估,运用Review Man5.3软件对最终纳入文献的研究数据进行meta分析.结果 共纳入7篇文献,种植体数共198枚,上颌窦例数170例.种植体脱落率非植骨组与植骨组差异无统计学意义,显示(RR=1.51,95％CI:0.32～7.81,P=0.610).骨增量方面,非植骨组临床效果差于植骨组(SMD=-2.28,95％CI:-3.27～-0.85,P=0.002),二者相差2.28 mm.种植体稳定性方面,非植骨组与植骨组差异无统计学意义(SMD=-0.03,95％CI:-0.45～0.38,P=0.870).结论 对于上颌窦侧壁窦底抬高术后即刻种植术中,在骨增量方面植骨组优于非植骨组,在种植体脱落率与种植体稳定性方面,二者无显著差异.

目的:调查县级医院中毒患者的临床特征及救治情况。方法:回顾性分析2015年4月至2019年4月江苏省人民医院溧阳分院中毒住院患者的资料。结果:共有480例急性中毒病例，农药（51.67%）和药物（28.75%）是最常见的毒物种类，以有机磷农药和镇静安眠类药物居多。自杀是最常见的原因（80.00%），90.00%为经口摄入中毒，77.65%的经口摄入中毒予以洗胃、3.23%予以催吐。42例行机械通气治疗，5例行血液净化治疗，5例行心肺复苏治疗。根据预后将患者分为治愈组、死亡组和自动出院组，其构成比分别为69.17%、1.67%和29.17%。结论:农药中毒的发生率最高，经口摄入是最常见的中毒途径，中毒的原因以自杀最为多见，洗胃、催吐、拮抗剂、机械通气等治疗已被常规开展。

目的:解决院前与院内急救数据的传输稳定性问题,提高急救信息互联互通水平.方法:基于5G和人工智能技术,在院内集成平台的基础上,对院前院内急诊系统进行标准化数据传输、医联体院前急救模式改造和统一调度平台建设,打通院前和院内急救系统.结果:院内医生可提前查看院前危重患者的生命体征、心电图等诊疗信息,并通过5G网络与患者或医生进行实时视频沟通或指导.结论:5G的高速率、低时延、大连接特性,可大大缩短抢救响应时间,提高患者救治效率,实现院前院内信息资源共享、院前院内急救系统信息互联互通,为院前急救、智慧医疗提供强大的技术支撑.

Objective:To evaluate the effect of mechanical chest compression device in patients with cardiac arrest.Methods:The relevant literatures about mechanical cardiopulmonary resuscitation and manual cardiopulmonary resuscitation were systematically searched from China Knowledge Network (CNKI), VIP, Wanfang, PubMed, Web of Science and other databases. The effective data were extracted and analyzed by RevMan5.3 software.Results:A total of 20 clinical studies involving 29 727 patients were included, of which 11 104 patients received mechanical cardiopulmonary resuscitation and 18 623 patients received traditional manual cardiopulmonary resuscitation. The results of meta-analysis showed that mechanical cardiopulmonary resuscitation could not effectively improve the restoration of spontaneous circulation (ROSC) rate, admission survival rate, discharge survival rate and neurological prognosis in patients with cardiac arrest compared with manual cardiopulmonary resuscitation. ROSC occurrence rate ( RR=1.10, 95% CI: 0.99-1.23, P<0.01), admission survival rate ( RR=1.01, 95% CI: 0.95-1.08, P=0.67), discharge survival rate ( RR=1.00, 95% CI: 0.86-1.15, P=0.14), and good neurological function rate ( RR=0.81, 95% CI: 0.61-1.06, P=0.69) showed no significant differences between the mechanical cardiopulmonary resuscitation and manual cardiopulmonary resuscitation. Conclusions:Mechanical chest compression device has no advantage compared with manual cardiopulmonary resuscitation. Mechanical cardiopulmonary resuscitation is not recommended to completely replace manual chest compression in cardiopulmonary resuscitation.

目的 分析急性冠脉综合征(acute coronary syndrome,ACS)导致的心源性休克患者使用静脉-动脉体外膜氧合(veno-arterial extracorporeal membrane oxygenation,VA-ECMO)治疗早期容量平衡与预后的相关性.方法 本研究回顾自2015年3月至2020年11月接受VA-ECMO治疗的患者,筛选出VA-ECMO运行>3 d并以ACS为病因的心源性休克患者.比较ACS患者与非ACS患者一般情况、联合连续肾脏替代治疗(continuous renal replacement therapy,CRRT)、主动脉内球囊反搏(intra-aortic balloon pump,IABP)及有创机械通气情况.统计ACS患者预后与前3 d每天容量平衡及总平衡的相关性.根据ACS患者的前3 d总容量的正负平衡分组,比较患者一般情况、肾功能指标及联合CRRT、IABP、有创机械通气的情况.结果 入选32例患者.ACS患者与非ACS患者在年龄、性别比例、是否联合IABP治疗方面比较差异有统计学意义(P<0.05).ACS患者根据前3 d每日容量平衡正负分组,正负两组存活率比较差异无统计学意义(P>0.05);根据前3 d总容量平衡结果进行分组,两组存活率比较差异有统计学意义(20.0％vs.58.8％,P<0.05),但两组年龄、性别比、VA-ECMO运转时间、肾功能变化比较差异无统计学意义(P>0.05),联合CRRT、IABP或有创通气等差异无统计学意义(P>0.05).结论 对于ACS导致的心源性休克患者,接受VA-ECMO支持治疗3 d以上时,前3 d总容量平衡呈负平衡的患者较正平衡患者存活概率更高.

Objective:To summarize the clinical experience of extracorporeal membrane oxygenation (ECMO) support in acute myocardial infarction (AMI) complicated by cardiogenic shock.Methods:Thirty-seven AMI patients received ECMO from March 2016 to October 2020 in Emergency Department of the First Affiliated Hospital of Nanjing Medical University were retrospectively analyzed. Gensini score was used to evaluate the coronary lesion severity, vasoactive-inotropic score (VIS) was used to assess the usage of vasoactive-inotropic drugs, and cumulative fluid balance (CFB) was used to calculate the fluid balance status, respectively. According to the infarct-related artery, positive/negative fluid balance, and survival/death outcome, the patients were divided into the negative and positive fluid balance groups, and the survival and death groups, respectively. The relationship between Gensini score, 24-hVIS, CFB and patient outcome was analyzed.Results:Thirty AMI-ECMO patients were enrolled, 12 patients survived and 18 died with a mortality rate of 60.0%, and 80.0% of the infarct-related artery were left main and proximal left anterior descending artery. The Gensini score was 77 (52, 120), 24-h VIS 50.0 (31.1, 80.4), daily fluid volume 28.7 (26.6, 34.4) mL/(kg·d), and CBF -1.8 (-9.7, 8.0) mL/kg. The mortality and 24-h VIS of the negative fluid balance group were significantly lower than those of the positive fluid balance group, and the Gensini score, 24-h VIS and CBF of the survival group were significantly lower than those of the death group.Conclusions:LM and pLAD are the most common infarct-related arteries in AMI-ECMO patients, the Gensini score and 24-h VIS have a certain prognostic value, and early negative fluid balance may improve the survival rate.

蛇咬伤后,结合实际情况以最恰当、最有效的方式进行干预,有效降低致残率、死亡率,初始应对措施极其重要.随着近年蛇伤中毒事件的增加,寻求快捷、适用、易操作的方式处理蛇伤,引起了大家的关注,特别是早期、有效地干预是当务之急.2020年Journal of Special Operations Medicine(JSOM)第2期发表的《联合战伤体系临床实践指南——全球蛇伤中毒处理》(以下简称"《指南》"),在蛇伤处理理念上进行了更新和系统化完善,尤其是初始处理上以简化判断方式,早期、快速选择合适抗蛇毒血清注射方法为特色,基于临床研究对传统绷带、止血带等处理伤肢提出了新的观点[1-5].虽然是基于战伤体系的实践指南,但值得我们学习和参考,为此特对《指南》的初期——初步处置措施(通用建议)进行解读.

目的 探究横纹肌溶解综合征(rhabdomyolysis,RM)患者血清肌红蛋白、肌酸激酶(creatine kinase,CK)以及二者比值对急性肾功能衰竭(acute kidney inj ury,AKI)的预测作用.方法 回顾性分析在江苏省人民医院及南京市浦口医院住院接受治疗的120例RM患者的临床资料,比较AKI患者和非AKI患者的血清CK、肌红蛋白浓度及两者比值,CK、肌红蛋白值和肌红蛋白/CK比值从最低到最高分为四分位数,统计AKI发生率、病死率以及分布,采用Spearman分析肌红蛋白、CK与AKI发生的相关性;分别采用单因素Logistic回归分析和多因素Logistic回归分析探究预测AKI的风险因子.结果 47例(39.16％)RM患者并发AKI,其中42例患者进行了血液透析治疗,经透析的患者发生2例死亡(病死率4.76％),其余患者全部存活.AKI患者和非AKI患者的血清肌红蛋白浓度和CK活性显著高于非AKI患者(P<0.05);经Spearman分析,血清肌红蛋白浓度、血清CK活性与AKI的发生的相关系数分别为:0.51(P=0.003)、0.22(P=0.019).多因素Logistic回归分析则表明血清肌红蛋白为AKI的显著预测因子,肌红蛋白/CK比值的第三、第四分位数均为AKI发生的显著预测因子(P<0.05).结论 血清肌红蛋白以及肌红蛋白/CK的比值是预测AKI的显著风险因子,建议在入院时即进行检测.